Purpose: We hypothesize that introduction of National Hospital Quality Measures (NHQM) by Joint Commission on Accreditation of Health Care Organizations (JCAHO) and Centers for Medicare and Medicaid Services (CMS) in 2004 to improve pneumonia and surgical infection outcomes may have resulted in a substantial increase of antibiotic usage, leading to upsurge of Clostridium difficile associated diarrhea and colitis in this inner city hospital. Methods: We reviewed charts of all patients with confirmed Clostridium difficile infection admitted to our hospital from January 1, 2003 to December 31, 2008. Antibiotic usage for all inpatients during the same period was also reviewed. Results: There were a total of 439 patients with confirmed Clostridium difficile infection from January 1, 2003 to December 31, 2008. We observed significant increase in Clostridium difficile infection rate between 2003 and 2008. The number of cases per 10,000 admissions were 16 in 2003, 20 in 2004, 50 in 2005, 36 in 2006, 40 in 2007, and 58 in 2008. The total number of antibiotic doses used per 1000 admissions were 3268 in 2003, 3536 in 2004, 4585 in 2005, 5150 in 2006, 5848 in 2007, and 5867 in 2008. Fluoroquinolones, cephalosporins, piperacillin/tazobactam, ampicillin/sulbactam, aztreonam and azithromycin were the major antibiotics used. The yearly average length of stay and number of stool samples tested remained same during this period. Conclusion: Introduction of National Hospital Quality Measures have lead to substantial increase in antibiotic usage. We believe this has resulted in increase in Clostridium difficile infections in our patient population. Antibiotic usage related quality measures may have resulted in unintended complications and should be reevaluated.

We read the paper by Chang et al. ([1][1]) and accompanying editorial ([2][2]) with great interest. The insightful single-center study addresses safety of normal stress-only myocardial perfusion imaging (MPI). However, it raises some concerns. Careful examination of the paper suggests a conundrum.

Ischemic electrocardiographic (ECG) changes during vasodilator stress testing (VST) in the presence of abnormal myocardial perfusion imaging (MPI) are uncommon and are associated with presence of multivessel coronary artery disease (CAD). However, there is a paucity of data regarding the significance of ischemic ECG changes during VST with normal MPI in general, and especially among African Americans and Hispanics.

Purpose: Patients admitted for acute myocardial infarction require multiple antiplatelet agents without any initial workup. We studied the incidence of gastrointestinal (GI) bleeding in patients undergoing primary percutaneous intervention (PCI) in an inner city population. Methods: We reviewed charts of 101 consecutive patients admitted for possible acute myocardial infarction (AMI) to the emergency room. Demographic information, laboratory values, medication lists, comorbid conditions and incidence of GI bleeding were abstracted. 57 patients admitted for AMI who underwent PCI were compared to 44 patients who were admitted for possible AMI but did not have PCI. Results: The mean age of the study population was 58±15yrs, 72% males, 75% Hispanics, 19% African American, 6% Others. The two groups were similar. There was no significant difference in comorbid conditions (coronary artery disease p=0.38, hypertension p=0.35, heart failure p=0.55, diabetes mellitus p=0.42, renal insufficiency p=0.16, chronic liver disease p=0.38). The admission laboratory values were also similar (baseline hemoglobin p=0.21, platelet count p=0.29, serum albumin p=0.33, serum creatinine p=0.26, international normalized ratio p=0.16, except the leukocyte count p=0.03 and AST p=0.02 which were higher in the PCI group). The mean number of antiplatelet agents used in the PCI group was 3.7 whereas in the control group it was 2.5, with a p<0.0001. There were two instances of GI bleeding in the PCI group and none in the control group, p=0.503. 30 day mortality was higher in the PCI group (10.5%) compared to the control group (0%), p=0.027. Conclusion: Chronic medical conditions which increase the chances of GI bleeding like chronic liver disease and thrombocytopenia tend to be more common in inner city population. However use of multiple antiplatelet agents in patients undergoing PCI appears to be safe and did not increase the incidence of GI bleeding.

Background: Transthoracic needle aspiration (TTNA) and core needle biopsy (CNB) are performed by a pulmonologist or an interventional radiologist (IR). Very few pulmonary fellowship programs offer training in TTNA/CBN. We compared the yield and complications of TTNA/CNB when performed by pulmonologist versus IR.Method: This was a retrospective analysis of patients that underwent TTNA/CNB from 2003 to 2007 at our institution. Procedures were performed by either, any of 5 pulmonary fellows under the supervision of any of 4 pulmonologists or by a single IR.Results: Thirty-five patients were included, 19 in the pulmonary and 16 in the IR group. There were no differences in yield (P=0.28) or complications (P=0.31) between the groups. The overall diagnostic yield was 63% for pulmonary versus 69% for IR. Malignancy was the most common diagnosis (70%). CNB was used by pulmonary in 21% compared with 50% of IR cases. The yield was higher when TTNA was combined with CBN (75% vs. 61% for TTNA alone). An on-site pathologist was present only during the pulmonary cases.Conclusions: The overall yield and complications were similar in both groups. Combining TTNA and CBN provides higher yield than TTNA alone. Obtaining expertise in CNB is of the outmost importance to maximize yield and decrease need for more invasive procedures. Pulmonary fellowship programs should continue to offer training in TTNA/CNB with an onsite pathologist where available, to achieve diagnostic yield comparable with the interventional radiologist. Those programs should develop a system to maintain proficiency for the faculty.

PURPOSE: CDC reports state that during 1980–2002, death rates and hospitalization rates for Pulmonary Hypertension (PH) as a contributing cause of death or any-listed hospital diagnosis increased. The present study sought to characterize the demographics, co morbidities and mortality in patients with severe pulmonary hypertension identified on Echocardiography (ECHO) in an inner city hospital.

Background: Though several modalities are available for colorectal cancer screening, only about half of adults are being screened.Barriers to compliance include fear of diagnosis, lack of motivation and logistical difficulties, including taking time off work.The aim of the study was to evaluate whether offering a paid day off from work would motivate more patients to undergo screening.Methods: A questionnaire was administered to employees at the the Bronx-Lebanon Hospital Center in 2007.Results: Of the 916 surveys returned, we focused on the 438 responders who needed a screening test due to age greater than 50, or less than 50 but with a family history of colon cancer.Of the 438, fifty responders were not sure or not willing to undergo screening.The remainder were willing or had been screened and were excluded from the analysis.Among the fifty, 17 (34%) were more willing to undergo screening when they were offered a paid day off from work.Six out of ten men (60%) changed their mind based on this incentive while only 11 out of 40 women (27%) did so (p= 0.05).Conclusions: A paid day off from work may increase screening compliance.This effect was more pronounced in men.

PURPOSE: To evaluate management and outcome of patients admitted with Delerium tremens (DT) to Intensive Care Unit (ICU) compared to patients without DT.

Purpose: The aims of our study were to examine the role of colonoscopy as further workup for bowel wall thickening reported on computed tomography (CT) scans and to investigate whether there were significant differences in pathology found among the racial groups in our study population.Methods: This is a retrospective study from March 2005 and January 2007 of all patients who have undergone colonoscopy for bowel wall thickening found on CT scans of the abdomen.Results: Of 94 patients with bowel wall thickening on CT scans, 7 (8%) had adenocarcinoma, 5 (5%) had large adenomas, 3 (3%) had infectious colitis, 2 (2%) ischemic colitis, 1 (1%) had inflammatory bowel disease, and 1 (1%) had a benign stricture. Bowel wall thickening on CT scan predicted clinical pathology in 34% of African Americans, as compared to 14% of Hispanics. Patients with significant pathology were more likely to have anemia and lower albumin levels.Conclusion: Patients with bowel wall thickening found on CT scans should be referred for colonoscopy, given that significant pathology is found in 20% of the cases. African Americans were 2.5 times more likely to have clinically significant pathology as compared to Hispanics.

PURPOSE: Treatment options for venous thromboembolism (VTE) include protocol driven unfractionated heparin (UFH) or low-molecular-weight heparins (LMWH) followed by oral warfarin. LMWH has been associated with decreased hospital length of stay (LOS) and fewer complications. The purpose of this study was to evaluate the time required to achieve therapeutic anticoagulation with UFH and to compare the complication rate, outcome, and hospital LOS for patients treated with UFH versus LMWH.

PURPOSE: Isolated abnormalities in DLCO are often seen during pulmonary function testing (PFT). There are very few studies evaluating the significance of these abnormalities.

PURPOSE: Intensive care unit (ICU) admission rate for obstetric patients in developed countries ranges from 4/1,000 to 9/1,000 deliveries. Common causes of admission are obstetric related complications and exacerbation of a co-morbid condition. To compare obstetric patients admitted to ICU with a non-ICU obstetric control group.

Anemia is prevalent among African American children. When evaluating pediatric patients for anemia, clinicians refer to the normative hematological reference values in reference textbooks. These reference values are used in spite of evidence that healthy African American people of all ages have average hemoglobin concentrations from 0.5 to 0.73 g/dl below those of Whites. In an earlier study, using samples from 2,161 healthy African American children from 2 to 18 years old, we found a statistically significant difference (P < 0.0001) in the mean hemoglobin value for each age group as compared to reference normative mean hemoglobin values. Here we present the results of a comparative analysis of the data set from our previous study and the data set from the National Health and Nutrition Examination Surveys III (NHANES III) 1988-1994. We found no statistically significant difference between these data sets with respect to the hemoglobin values for any age or sex group, confirming that African American children and adolescents have lower mean hemoglobin values than do Whites. Use of the reference hemoglobin values presented here will help prevent the misdiagnosis of anemia in African American children and thereby minimize unnecessary hematological workups and treatment.

BACKGROUND: In the United States, among patients with hepatocellular carcinoma (HCC) and portal hypertension from chronic hepatitis-B virus infection, 44% were Hispanic and 28% were African American. Because our institution (Bronx Lebanon Hospital Center, Bronx, NY) predominantly serves these populations, we studied retrospectively the characteristics of patients with chronic hepatitis-B virus infection. METHODS: We reviewed the medical records of all patients aged > 18 years with chronic hepatitis-B virus infection who had been evaluated at our institution between January 1, 2002 and May 31, 2005. RESULTS: We identified 167 patients with chronic hepatitis-B virus infection. Only 12 (7%) patients underwent chronic hepatitis-B virus treatment. One-hundred-forty-six (87%) patients without decompensated liver cirrhosis were not treated owing to the following reasons: normal alanine aminotransferase level (86%), active injection drug or heavy alcohol use (9%), lack of health insurance coverage (3%) and noncompliance with visits during the evaluation period (2%). HCC screening was performed in 78 patients (47%). Lack of insurance coverage and compliance issues were predictors for HCC screening (p = 0.04 and p < 0.001, respectively). CONCLUSIONS: In the South Bronx, 87% patients were not considered candidates for hepatitis-B virus treatment because of normal alanine aminotransferase levels and the interference of potentially modifiable social factors. Only 47% of our patients with chronic hepatitis-B virus infection underwent HCC screening because of lack of insurance coverage and compliance issues.

PURPOSE: Implementation of lung protective strategies and fluid restriction has been shown to improve outcome in ARDS. Reported predictors of mortality include age, etiology of ARDS and HIV status among others. The objective of the study is to compare etiology and determinants of outcome for ARDS in HIV positive and HIV negative/unknown patients.

BACKGROUND Myocardial perfusion imaging (MPI) is a well-established diagnostic method for evaluation and risk stratification of coronary artery disease (CAD). We undertook this study to validate both the positive predictive value (when compared to cardiac catheterization) and the prognosis afforded by MPI in a group of minority women patients. MATERIAL/METHODS The database of our Nuclear Imaging and Catheterization Laboratory was retrospectively queried for consecutive minority (African-American, Hispanic and Asian) women patients who underwent MPI and cardiac catheterization within 90 days of each other. Patients with recent revascularization were excluded. Attenuation/scatter correction was utilized in the final interpretation of the study. RESULTS Of the 54 women patients who underwent MPI, 7 underwent exercise stress testing, 26 had stress testing with adenosine, 18 with dipyridamole and 3 with dobutamine. Eighteen patients (53%) had same number of vessels predicted by MPI and coronary angiography (7 patients with triple vessel disease, 7 with 2-vessel disease and 4 with single vessel disease). Five (3 with intermediate and 2 with high risk scans) out of the 54 patients (9.3%) were dead at 2 years. The sensitivity, specificity and positive predictive value of MPI as compared to angiography were 87.2%, 26.7%, 75.6% and 44.4% respectively. CONCLUSIONS The sensitivity of MPI in this group of patients is comparable to the general population though the specificity is lower in spite of using attenuation and scatter correction. Low risk perfusion scan signifies favorable prognosis at 2 years with regards to mortality.